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Pemicu 1

“Buramnya Mata Ini”


Adrian Pratama – 405100018 – Blok Penginderaan
LO 1
 Menjelaskan anatomi mata
Orbit
 bony cavities in the facial skeleton that resemble hollow
quadrangular pyramids
 bases directed anterolaterally
 Apices directed posteromedially
 medial walls of the two orbits, separated by the ethmoidal
sinuses and the upper parts of the nasal cavity, are
parallel, whereas their lateral walls are nearly at a right
(90°) angle
 axes of the orbits diverge at approximately 45°
 The optical axes (axes of gaze, the direction or line of
sight) for the two eyeballs, are parallel
 The pyramidal orbit has a base, four walls, and an apex
 Base
 outlined by the orbital margin that surrounds the orbital opening
 Superior wall
 approximately horizontal and is formed mainly by the orbital part of
the frontal bone
 Near the apex of the orbit, the superior wall is formed by the lesser
wing of the sphenoid
 Anterolaterally, a shallow depression in the orbital part of the frontal
bone, called the fossa for the lacrimal gland
 Medial wall
 formed primarily by the ethmoid bone, along with contributions from the
frontal, lacrimal, and sphenoids
 Anteriorly, the medial wall is indented by the lacrimal groove and fossa for
the lacrimal sac
 “Paper thin”
 Inferior wall
 formed mainly by the maxilla and partly by the zygomatic and palatine
bones
 inferior wall is demarcated from the lateral wall of the orbit by the inferior
orbital fissure
 Lateral wall
 formed by the frontal process of the zygomatic bone and the greater wing
of the sphenoid
 strongest and thickest wall
 Apex  at the optic canal in the lesser wing of the sphenoid just
medial to the superior orbital fissure
Eyelids
 cover the eyeball anteriorly, thereby protecting it from injury
and excessive light
 keep the cornea moist by spreading the lacrimal fluid
 covered externally by thin skin and internally by transparent
mucous membrane, the palpebral conjunctiva
 part of the conjunctiva is reflected onto the eyeball, where it is
continuous with the bulbar conjunctiva
 lines of reflection of the palpebral conjunctiva onto the eyeball
form deep recesses  superior and inferior conjunctival fornices
 conjunctival sac  space bound by the palpebral and bulbar
conjunctivae
  enables the eyelids to move freely over the surface of the eyeball
as they open and close
 strengthened by dense bands of connective tissue 
superior and inferior tarsi
 Embedded in the tarsi are tarsal glands  lipid secretion of
which lubricates the edges of the eyelids and prevents them
from sticking together when they close
 Eyelashes  in the margins of the lids
 junctions of the superior and inferior eyelids make up the medial
and lateral palpebral commissures  angles of the eye
(canthus)
 Between the nose and the medial angle of the eye is the
medial palpebral ligament
 connects the tarsi to the medial margin of the orbit
 lateral palpebral ligament
 attaches the tarsi to the lateral margin of the orbit
Lacrimal apparatus
 Lacrimal glands
 secrete lacrimal fluid, a watery physiological saline containing
the bacteriocidal enzyme lysozyme
 moistens and lubricates the surfaces of the conjunctiva and
cornea
 provides some nutrients and dissolved oxygen to the cornea
 Lacrimal ducts
 convey lacrimal fluid from the lacrimal glands to the conjunctival
sac
 Lacrimal canaliculi
 commence at a lacrimal punctum on the lacrimal papilla & drain
lacrimal fluid from the lacrimal lake to the lacrimal sac
 Nasolacrimal duct
The eyeball
 contains the optical apparatus of the visual system and
occupies most of the anterior portion of the orbit
 The loose connective tissue layer 
 Anterior : bulbar conjunctiva
 Posterior : bulbar fascia
 The layers of the eyeball
 Fibrous layer (outer coat),
 consisting of the sclera and cornea
 Vascular layer (middle coat),
 consisting of the choroid, ciliary body, and iris
 Inner layer (inner coat),
 consisting of the retina that has both optic and non-visual parts
Inner layer
 Retina
 Optic part  sensitive to visual light rays
 neural layer: light receptive
 pigment cell layer: reinforces the light-absorbing property of the
choroid in reducing the scattering of light in the eyeball
 Non-visual retina
 anterior continuation of the pigment cell layer and a layer of
supporting cells over the ciliary body (ciliary part of the retina)
 posterior surface of the iris (iridial part of the retina)
 Fundus
  posterior part of the eyeball
 optic disc: sensory fibers and vessels conveyed by the optic nerve
 macula lutea: small oval area of the retina with special photoreceptor
cones that is specialized for acuity of vision
 fovea centralis: the area of most acute vision

 Arteries & veins


 retina is supplied by the central artery of the retina, a branch
of the ophthalmic artery
 corresponding system of retinal veins unites to form the central
vein of the retina
Refractive Media of the Eyeball
 Cornea
 circular area of the anterior part of the outer fibrous layer of
the eyeball
 largely responsible for refraction
 Transparent; regular arrangement of its collagen fibers
 Avascular
 Sensitive to touch
 nourishment is derived from the capillary beds at its periphery,
the aqueous humor, and lacrimal fluid
 Innervated by N. V1
 Aqueous humor
 produced in the posterior chamber by the ciliary processes of
the ciliary body 
 passing through the pupil into the anterior chamber 
 drains into the scleral venous sinus/canal of Schlemm at
iridocorneal angle 
 removed by the limbal plexuses 
 vorticose and the anterior ciliary veins

 provides nutrients for the avascular cornea and lens


 Lens
 posterior to the iris and anterior to the vitreous humor of the
vitreous body
 transparent, biconvex structure enclosed in a capsule
 anchored by the zonular fibers (suspensory ligament of the lens)
to the ciliary body and encircled by the ciliary processes
 ciliary muscle in the ciliary body changes the shape of the lens

 Vitreous humor
 watery fluid enclosed in the meshes of the vitreous body;
transparent jelly-like substance in the posterior four fifths of the
eyeball posterior to the lens
 holds the retina in place and supports the lens
Extraocular muscles of the orbit
 Levator Palpebrae Superioris
 broadens into a wide bilaminar aponeurosis as it approaches its
distal attachments
 superficial lamina attaches to the skin of the superior eyelid
 deep lamina to the superior tarsus
 opposed most of the time by gravity
 antagonist of the superior half of the orbicularis oculi, the
sphincter of the palpebral fissure
 The deep lamina includes smooth muscle fibers, the superior
tarsal muscle  additional widening of the palpebral fissure
during a sympathetic response (e.g., fright)
Fascial Sheath of the Eyeball
 ~fascia bulbi, Tenon capsule
 envelops the eyeball from the optic nerve nearly to the
corneoscleral junction, forming the actual socket for the
eyeball
 is pierced by the tendons of the extraocular muscles and is
reflected onto each of them as a tubular muscle sheath
 The muscle sheaths of the levator and superior rectus
muscles are fused; thus, when the gaze is directed
superiorly, the superior eyelid is further elevated out of the
line of vision
 Triangular expansions from the sheaths of the medial and
lateral rectus muscles, called the medial and lateral check
ligaments, are attached to the lacrimal and zygomatic bones 
limit abduction and adduction
 blending of the check ligaments with the fascia of the inferior
rectus and inferior oblique muscles forms a hammock-like sling
 suspensory ligament of the eyeball
 potential episcleral space between the eyeball and the fascial
sheath allows the eyeball to move inside the cup-like sheath
 similar check ligament from the fascial sheath of the inferior
rectus  retracts the inferior eyelid when the gaze is directed
downward
Arteries of the orbit
Veins of the orbit
LO 2
 Menjelaskan histologi mata
Layers of the eye
Fibrous layer
 Sclera
 protects the more delicate internal structures and provides sites
for muscle insertion
 0.5 mm in thickness, is relatively avascular, and consists of tough,
dense connective tissue containing flat type I collagen bundles,
moderate amount of ground substance and scattered fibroblasts
 adjacent to the choroid  slightly less dense, with thinner
collagen fibers, more fibroblasts, elastic fibers, and melanocytes
 Cornea
 colorless, transparent, and completely avascular
 an external stratified squamous epithelium
 an anterior limiting membrane (Bowman's membrane, the
basement membrane of the stratified epithelium)
 the stroma
 a posterior limiting membrane (Descemet's membrane, the
basement membrane of the endothelium)
 an inner simple squamous endothelium
Corneo-scleral junction
Sclera, choroid, & retina
-. Choroid
highly vascular tunic in the posterior
two-thirds of the eye, with loose,
well-vascularized connective tissue
rich in collagen and elastic fibers,
fibroblasts, melanocytes,
macrophages, lymphocytes, mast
cells, and plasma cells
Cilliary body
 anterior expansion of the choroid at the level of the lens
 has a stroma of loose connective tissue, rich in
microvasculature, elastic fibers, and melanocytes,
surrounding much smooth muscle
 ciliary muscle  important in visual accommodation
Iris
 the most anterior extension of the uvea (middle layer) that
partially covers the lens, leaving a round opening in the
center called the pupil
 anterior surface of the iris,  not covered by epithelium,
but consists of an irregular, discontinuous layer of
fibroblasts and melanocytes
 posterior surface of the iris is smooth, with a two-layered
epithelium continuous with that covering the ciliary body
and its processes
Lens
 transparent biconvex structure immediately behind the iris,
used to focus light on the retina

 Lens casule
 homogeneous capsule rich in proteoglycans and type IV
collagen
 Lens epithelium
 homogeneous capsule rich in proteoglycans and type IV
collagen
 Lens fibers
 Developing from stem cells in the lens epithelium, the
differentiating lens fibers eventually lose their nuclei and other
organelles, fill the cytoplasm with a group of proteins called
crystallins
Vitreous body
 transparent connective tissue containing mostly (99%)
water (vitreous humor), bound to hyaluronate, and a small
amount of collagen
 contained within the vitreous membrane composed of type
IV collagen and other proteins of external laminae
 few macrophages and a small population of cells near the
membrane called hyalocytes, which synthesize the
hyaluronate and collagen
Retina
 neural retina, contains the neurons and photoreceptors
 The outer pigmented layer is an epithelium resting on
Bruch's membrane just inside the choroid, function:
 serve as an important part of the blood-retina barrier
 absorb light passing through the retina to prevent its reflection
 phagocytose shed components from the adjacent rods and cones
 remove free radicals
 isomerize and regenerate the retinoids used as chromophores
by the rods and cones
Specialized Areas of the Retina
(fovea centralis, macula lutea, optic disc)
Conjunctiva & eyelids
Lacrimal glands
 produce fluid continuously for the tear film that moisturizes
and lubricates the cornea and conjunctiva and supplies O2
to the corneal epithelial cells
 contains various metabolites, electrolytes, and proteins,
including lysozyme, an enzyme that hydrolyzes the cell
walls of certain species of bacteria
LO 3
 Menjelaskan fisiologi penglihatan
Function of the parts of the eye
Refraction
 Light rays travel through air at a velocity of about
300,000 km/sec, but they travel much slower through
transparent solids & liquids
 When light rays traveling forward in a beam strike an
interface that is perpendicular to the beam, the rays enter
the second medium without deviating from their course
 If the light rays pass through an angulated interface, the
rays bend if the refractive indices of the two media are
different from each other (refraction)
 Because the direction in which light travels is always
perpendicular to the plane of the wave front
“Depth of focus” of the lense system
if the retina is moved forward or
backward to an out-of-focus
position, the size of each spot
will not change much in the
upper eye, but in the lower
eye the size of each spot will
increase greatly, becoming
a “blur circle.”

upper lens system has far


greater depth of focus than the
bottom lens system

“Depth of Focus” of the Lens


System Increases with
Decreasing
Pupillary Diameter
Error of refraction
Visual acuity
 light from a distant point source, when focused on the
retina, should be infinitely small
 because the lens system of the eye is never perfect, such a
retinal spot ordinarily has a total diameter of about 11
micrometers, even with maximal resolution of the normal
eye optical system
 the spot of light has a bright center point and shaded edges
 a person can normally distinguish two separate points if
their centers lie as much as 2 micrometers apart on the
retina
The normal visual acuity of
the human eye for
discriminating between point
sources of light is about 25
seconds of arc (light rays
from two separate points
strike the eye with an angle
of at least 25 seconds
between them)

 Person with normal visual


acuity looking at two bright
pinpoint spots of light 10
meters away can barely
distinguish the spots as
separate entities when they
are 1.5 to 2 millimeters apart
Convergence
 Characteristic of binocular vision
 allows the perception of depth and an appreciation of the
three-dimensional nature of objects
 occurs when light rays from an object strike corresponding points
on the two retinas

 medial movement of the two eyeballs so that both are


directed toward the object being viewed
 The nearer the object, the greater the degree of convergence
needed to maintain binocular vision
The flow of aqueous humor
Photochemistry of vision
Photochemistry of color vision by the cones
& Dark adaptation by cones & rods
Neural circuitry of retina
Functions of retinal cells
 Horizontal cells
  lateral inhibition
 Bipolar cells
 Excitation & inhibition
 Amacrine cells
 part of the direct pathway for rod vision
 responds strongly at the onset of a continuing visual signal
 respond strongly at the offset of visual signal
 respond when a light is turned either on or off
 responds to movement of a spot across the retina in a specific
direction
 Ganglion cells
 spontaneous, continuous action potential
 Transmission of Rod Vision by the W Cells
 important for much of our crude rod vision under dark conditions
 Transmission of the Visual Image and Color by the X Cells
 eceives input from at least one cone, X cell transmission is probably
responsible for all color vision
 Function of the Y Cells to Transmit Instantaneous Changes in the
Visual Image

 Transmission of Changes in Light Intensity—The On-Off


response
Visual pathway
LO 4
 Menjelaskan gangguan penglihatan mata tenang +
penurunan visus perlahan
Glaucoma
Definition
 acquired chronic optic neuropathy characterized by optic
disk cupping and visual field loss
 usually associated with elevated intraocular pressure
 majority of cases  no associated ocular disease (primary
glaucoma)
Classification
 Mechanism of raised intraocular pressure in glaucoma
 impaired outflow of aqueous resulting from abnormalities within
the drainage system of the anterior chamber angle (open-angle
glaucoma)
 impaired access of aqueous to the drainage system (angle-
closure glaucoma)
Physiology of aqueous humor
Pathophysiology
 retinal ganglion cell apoptosis  thinning of the inner
nuclear and nerve fiber layers of the retina and axonal
loss in the optic nerve  visual loss
 intraocular pressure elevation
 acute angle-closure glaucoma (60-80 mmHg)  acute ischemic
damage to the iris with associated corneal edema and optic
nerve damage
 primary open-angle glaucoma (intraocular pressure does not
usually rise above 30 mm Hg)  retinal ganglion cell damage
develops over a prolonged period, often many years
 normal-tension glaucoma  retinal ganglion cells may be
susceptible to damage from intraocular pressures in the normal
range
 major mechanism of damage may be optic nerve head ischemia
Clinical assessment
 Tonometry
 The most widely used instrument is the Goldmann applanation
tonometer
 The normal range of intraocular pressure is 10–21 mm Hg
 In the elderly, average intraocular pressure is higher, giving an upper
limit of 24 mm Hg
 In primary open-angle glaucoma, 32–50% of affected
individuals will have a normal intraocular pressure when first
measured
 Conversely, isolated raised intraocular pressure does not necessarily
mean that the patient has primary open-angle glaucoma, since other
evidence in the form of a glaucomatous optic disk or visual field
changes is necessary for diagnosis
 Gonioscopy
If it is possible to visualize
the full extent of the
trabecular meshwork, the
scleral spur, and the iris
processes, the angle is
open

able to see only


Schwalbe's line or a small
portion of the trabecular
meshwork means that the
angle is narrow

unable to see Schwalbe's


line means that the angle is
closed
 Optic disk assessment
 Visual field examination
Medical treatment
 Suppression of Aqueous Production
 Topical beta-adrenergic blocking agents
 Timolol maleate 0.25% and 0.5%, betaxolol 0.25% and 0.5%,
levobunolol 0.25% and 0.5%, metipranolol 0.3%, and carteolol 1%
solutions twice daily
 timolol maleate 0.1%, 0.25%, and 0.5% gel once daily in the morning
 Apraclonidine (0.5% solution three times daily and 1% solution
before and after laser treatment)
 Brimonidine (0.2% solution twice daily)
 Systemic carbonic anhydrase inhibitors—acetazolamide (125–
250 mg up to four times daily)
 Facilitation of Aqueous Outflow
 prostaglandin analogs
 bimatoprost 0.003%, latanoprost 0.005%, and travoprost 0.004%
solutions, each once daily at night
 unoprostone 0.15% solution twice daily
 Parasympathomimetic agents
 Carbachol 0.75–3%
 Epinephrine, 0.25–2% instilled once or twice daily
 Reduction of Vitreous Volume
 Hyperosmotic agents
 Oral glycerin (glycerol), 1 mL/kg of body weight in a cold
50% solution mixed with lemon juice
 Miotics, Mydriatics, and Cycloplegics
 Constriction of the pupil is fundamental to the management of
primary angle-closure glaucoma and the angle crowding of
plateau iris
 Pupillary dilation is important in the treatment of angle closure
secondary to iris bombé due to posterior synechiae
 angle closure is secondary to anterior lens displacement,
cycloplegics (cyclopentolate and atropine) are used to relax the
ciliary muscle and thus tighten the zonular apparatus in an
attempt to draw the lens backward
Surgical & Laser Treatment
 Peripheral Iridotomy, Iridectomy, and Iridoplasty
 Laser Trabeculoplasty
 Glaucoma Drainage Surgery
 Trabeculectomy
 bypass the normal drainage channels, allowing direct access from the
anterior chamber to the subconjunctival and orbital tissues
 Viscocanalostomy and deep sclerectomy with collagen
implant
 Goniotomy
 Cyclodestructive Procedures
Primary Open-Angle Glaucoma
 four times more common and six times more likely to cause
blindness in blacks
 1.29–2% of persons over age 40, rising to 4.7% of
persons over age 75 (U.S.)

 Chief pathologic features


 degenerative process in the trabecular meshwork  deposition
of extracellular material within the meshwork and beneath the
endothelial lining of Schlemm's canal  reduction in aqueous
drainage leading to a rise in intraocular pressure
 Raised intraocular pressure  optic disk and visual field
changes by months to years
 Some eyes tolerate elevated intraocular pressure without developing
disk or field changes (ocular hypertension)
 others develop glaucomatous changes with consistently "normal"
intraocular pressure (low-tension glaucoma)
 higher levels of intraocular pressure are associated with greater
field loss at presentation
 When there is glaucomatous field loss on first examination, the
risk of further progression is much greater
 Diagnosis
 glaucomatous optic disk or field changes are associated with
elevated intraocular pressures
 normal-appearing open anterior chamber angle
 no other reason for intraocular pressure elevation

 one-third of patients with primary open-angle glaucoma have a


normal intraocular pressure when first examined  repeated
tonometry may be necessary
Primary Angle-Closure Glaucoma
 occurs in anatomically predisposed eyes without other
pathology
 condition may manifest as an ophthalmic emergency or
may remain asymptomatic until visual loss occurs

 Pathology features
 Elevation of intraocular pressure is a consequence of obstruction
of aqueous outflow by occlusion of the trabecular meshwork by
the peripheral iris
 Risk factors
 age, female gender, family history of glaucoma, and South-East
Asian, Chinese, or Inuit ethnic background

 Diagnosis
 examination of the anterior segment and careful gonioscopy
 primary angle closure has resulted in optic nerve damage and
visual field loss
Diabetic Retinopathy
Risk factor & epidemiology
 Chronic hyperglycemia, hypertension,
hypercholesterolemia, and smoking
 Young people with type I (insulin-dependent) diabetes do
not develop retinopathy for at least 3–5 years after the
onset of the systemic disease
 Type II (non–insulin-dependent) diabetics may have
retinopathy at the time of diagnosis
Screening
 should be performed within 3 years from diagnosis in type I
diabetes, on diagnosis in type II diabetes  annually
thereafter in both types
 Digital fundal photography has been proven to be an effective
and sensitive method for screening
 Seven-field photography is the gold standard
 Mydriasis is necessary for best quality photographs, especially
if there is cataract

 Diabetic retinopathy can progress rapidly during pregnancy


 pregnant diabetic woman should be examined by an ophthalmologist
or digital fundal photography in the first trimester and at least every
3 months until delivery
Classification
 Nonproliferative Retinopathy
small-vessel damage and occlusion
 thickening of the capillary endothelial basement membrane and
reduction of the number of pericytes  microaneurysm

 Mild nonproliferative retinopathy  1 microaneurysm


 moderate nonproliferative retinopathy  extensive
microaneurysms, intraretinal hemorrhages, venous beading,
and/or cotton wool spots
 Severe nonproliferative retinopathy  cotton-wool spots, venous
beading, and intraretinal microvascular abnormalities (IRMA)
 Diagnose  intraretinal hemorrhages in four quadrants, venous
beading in two quadrants, or severe intraretinal microvascular
abnormalities in one quadrant
 Maculopathy
 breakdown of the inner blood–retinal barrier at the level of the
retinal capillary endothelium  leakage of fluid and plasma
constituents into the surrounding retina  focal or diffuse retinal
thickening or edema
 common in type II diabetes and requires treatment once it
becomes clinically significant
 Proliferative Retinopathy
 most severe ocular complications of diabetes mellitus
 Progressive retinal ischemia  formation of delicate new
vessels that leak serum proteins (and fluorescein) profusely
 Early  presence of any new vessels on the optic disk or
elsewhere in the retina
 High risk characteristic
 new vessels on the optic disc extending more than one-third disk
diameter,
 any new vessels on the optic disk with associated vitreous hemorrhage,
 new vessels elsewhere in the retina extending more than one-half disk
diameter with associated vitreous hemorrhage
Treatment
 good control of hyperglycemia, systemic hypertension, and
hypercholesterolemia
 Intravitreal injections of triamcinolone or anti-VEGF agents
 pan-retinal laser photocoagulation (PRP)
 inducing regression of new vessels
 Vitrectomy is able to clear vitreous hemorrhage and
relieve vitreoretinal traction
Age related macular degeneration
Definition & epidemiology
 complex multifactorial progressive disease with genetic
and environmental influences
 leading cause of irreversible blindness in the developed
world
 occurs in people aged over 55
 Risk factors
 increasing age, white race, and smoking
Pathogenesis
 degeneration of the retinal pigment epithelium, linked to
oxidative stress
 Changes in the adjacent extracellular matrix of Bruch's
membrane and the formation of subretinal deposits
 diffuse thickening of Bruch's membrane 
 oxygen diffusion into retinal pigment epithelium and photoreceptors <

 release of growth factors and cytokines 
 growth of choroidal new vessels 
 grow through into the subretinal space 
 choroidal neovascular membrane 
 new vessels leak serous fluid and/or blood  distortion and reduction
of clarity of central vision 
 progression of the degenerative process to cell death and atrophy of
the retinal pigment epithelium  visual loss
Early Age-Related Macular Degeneration
 characterized by limited drusen, pigmentary change, or
retinal pigment epithelial atrophy
 associated visual impairment is variable and may be
minimal
 Fluorescein angiography  irregular patterns of retinal
pigment epithelial hyperplasia and atrophy
Late Age-Related Macular Degeneration
 Geographic atrophy ("dry age-related macular
degeneration")
 well-demarcated areas, larger than two disc diameters, of
atrophy of the retinal pigment epithelium and photoreceptor
cells, allowing direct visualization of the underlying choroidal
vessels
 Neovascular ("wet") age-related macular degeneration
 development of choroidal neovascularization or serous retinal
pigment epithelial detachment
 Hemorrhagic detachment of the retina may undergo fibrous
metaplasia  elevated subretinal mass (disciform scar)
 early hyperfluorescence, which is usually well circumscribed and
may have a lacy pattern
 Risk of Progression to Late Age-Related Macular
Degeneration
 patients with no late disease
 each eye with large drusen/each eye with pigmentary
abnormalities/neither eye has large drusen for intermediate-size
drusen present in both eyes  1 point
 For patients with late disease in one eye
 eye with late disease  2 points
 each of large drusen or pigmentary abnormalities in the fellow eye 
1 point

  5-year risk of progression to late age-related macular


degeneration is 0.5%, 3.0%, 12.0%, 25%, and 50%,
respectively, as the cumulative score rises from 0 to 4
Prophylactic Therapy
 vitamins and antioxidants
 vitamin C (500 g), vitamin E (400 IU), betacarotene (15 mg),
and zinc (80 mg) and copper (2 mg) daily
 Retinal laser photocoagulation
 reduces the extent of drusen but increases the rate of choroidal
neovascularization and is not recommended outside a clinical
trial
 Stop smoking
Treatment of Neovascular Age-Related Macular
Degeneration
 Conventional retinal laser photocoagulation
 photodynamic therapy
 anti-VEGF therapy
 Pegaptanib (intravitreal injection every 6 weeks)
 binds the major pathogenic isoform of vascular endothelial
growth factor, VEGF165
 Ranibizumab
 able to bind all isoforms of VEGF
 Bevacizumab
 Surgery (part of clinical trial)
 surgical removal of the choroidal neovascular membrane,
macular translocation, and retinal pigment epithelial
transplantation
Retinitis pigmentosa
Definition & symptoms
 group of heterogeneous hereditary retinal degenerations
characterized by progressive dysfunction of the
photoreceptors, associated with progressive cell loss and
eventual atrophy of several retinal layers
 autosomal recessive, autosomal dominant, or X-linked recessive
 Digenic and mitochondrial inheritance may also be responsible

 Symptoms
 night blindness (nyctalopia) and gradually progressive
peripheral visual field loss as a result of increasing and
coalescing ring scotomas
Diagnosis & examination
 Fundoscopic findings
 attenuated retinal arterioles, waxy pale optic disc, mottling of
the retinal pigment epithelium, and peripheral retinal pigment
clumping, referred to as "bone-spicule formation"
Treatment
 should be referred to specialized centers for genetic
counseling and selective mutation analysis
  Genetic analysis is useful to identify female carriers in
families with X-linked disease and to diagnose dominant
disease
Refraction disorder
Presbyopia
 The loss of accommodation that comes with aging to all
people
 inability to read small print or discriminate fine close
objects
 About age 44-46 increase until about age 55, when they
stabilize but persist
 worse in dim light and usually worse early in the morning
or when the subject is fatigued.
 Therapy
 corrected by  a plus lens  make up for the lost automatic
focusing power of the lens
 Fine for reading but blurred for distant objects  leaving the
top open and uncorrected for distance vision
Myopia
 When the image of distant objects focuses in front of the retina
in the unaccommodated eye or nearsighted
 If the eye is longer than average, the error is called axial
myopia
 If the refractive elements are more refractive than average, the
error is called curvature myopia or refractive myopia
 Prognosis  high degree of myopia  susceptibility to
degenerative retinal changes, including retinal detachment
 Concave spherical (minus) lenses are used to correct the image
in myopia
Hyperopia
 the state in which the unaccommodated eye would focus the
image behind the retina
 A young person may obtain a sharp distant image by
accommodating, as a normal eye would to read
 The young hyperopic person may also make a sharp near
image by accommodating more
 Classification
 reduced axial length (axial hyperopia) in certain congenital disorders
 reduced refractive error (refractive hyperopia), as exemplified by
aphakia
 Prognosis  esotropia , monocular amblyopia
Astigmatism
 the eye produces an image with multiple focal points or lines
 regular astigmatism  two principal meridians, with constant
power and orientation across the pupillary aperture, resulting in
two focal lines
 astigmatism with the rule  greater refractive power is in the
vertical meridian
 astigmatism against the rule  the greater refractive power is in the
horizontal meridian
 Oblique astigmatism  regular astigmatism in which the principal
meridians do not lie within 20 degrees of the horizontal and vertical
 irregular astigmatism  the power or orientation of the
principal meridians changes across the pupillary aperture
 Etiology  abnormality of corneal shape
 corrected with cylindrical lenses, frequently in combination
with spherical lenses
Anisometropia
 Anisometropia is a difference in refractive error between
the two eyes
 major cause of amblyopia because the eyes cannot
accommodate independently and the more hyperopic eye
is chronically blurred
 Refractive correction of anisometropia is complicated by
differences in size of the retinal images (aniseikonia)
 Correction
 Spectacle  difference in retinal image size of approximately
25%, which is rarely tolerable
 Contact lens  difference in image size to approximately 6%,
which can be tolerated
 Intraocular lens  difference of less than 1%
LO 5
 Menjelaskan gangguan penglihatan mata tenang +
penurunan visus mendadak
Retinal detachment
Definition
 the separation of the sensory retina, ie, the photoreceptors
and inner tissue layers, from the underlying retinal pigment
epithelium

 3 types
 Rhegmatogenous
 Traction
 Hemorrhagic
Rhegmatogenous Retinal Detachment
 most common type of retinal detachment
 usually preceded or accompanied by posterior vitreous
detachment and is associated with
 myopia, aphakia, lattice degeneration, and ocular trauma

 Characteristics
 full-thickness break in the sensory retina
 variable degrees of vitreous traction
 passage of liquefied vitreous through the break into the
subretinal space
 Binocular indirect ophthalmoscopy with scleral depression
 elevation of the translucent detached sensory retina with one or
more full-thickness sensory retinal breaks
 such as a horseshoe tear,
 most common in the superotemporal quadrant
 round atrophic hole,
 temporal quadrants
 anterior circumferential tear (retinal dialysis)
 inferotemporal quadrant
 Treatment
 Principal aim  treat all the retinal breaks
 cryotherapy or laser being applied to
 create an adhesion between the pigment epithelium and the sensory retina,
 preventing any further influx of fluid into the subretinal space,
 to drain subretinal fluid, internally or externally,
 relieve vitreo-retinal traction
 Surgery techniques:
 pneumatic retinopexy
 air or expandable gas is injected into the vitreous to maintain the retina in
position, while the chorioretinal adhesion induced
 Scleral buckling
 maintains the retina in position, while the chorioretinal adhesion forms, by
indenting the sclera with a sutured explant in the region of the retinal break
 Pars plana vitrectomy
 relief of vitreo-retinal traction, internal drainage of subretinal fluid,
Traction Retinal Detachment
 most commonly due to proliferative diabetic retinopathy
 can also be associated with proliferative vitreoretinopathy,
retinopathy of prematurity, or ocular trauma

 Characteristics
 has a more concave surface and is likely to be more localized,
usually not extending to the ora serrata
 tractional forces actively pull the sensory retina away from the
underlying pigment epithelium toward the vitreous base
 Traction is due to formation of vitreal, epiretinal, or subretinal
membranes consisting of fibroblasts and glial and retinal pigment
epithelial cells
 Treatment
 Pars plana vitrectomy allows removal of the tractional elements
followed by removal of the fibrotic membranes
 Retinotomy and/or injection of perfluorocarbons or heavy
liquids may be required to flatten the retina
 Gas tamponade, silicone oil, or scleral buckling may be used
Serous & Hemorrhagic Retinal Detachment
 occurs in the absence of either retinal break or
vitreoretinal traction
 form as a result of accumulation of fluid beneath the
sensory retina and are caused primarily by diseases of the
retinal pigment epithelium and choroid
 Degenerative, inflammatory, and infectious diseases 
subretinal neovascularization  serous retinal detachment
 may also be associated with systemic vascular and
inflammatory disease
Amaurosis fugaks
Definisi, etiologi, & gambaran klinis
 Buta sekejap satu mata yg berulang
 Etiologi
 Hipotensi ortostatik, spasme pemb darah, aritmia, migrain
retina, anemia, arteritis, koagulopati

 Gelap sementara selama 2-5 detik & normal kembali


sesudah beberapa menit/jam, disertai gangguan kampus
segmental, tanpa rasa sakit & terdapatnya gejala2 sisa
 Hilang penglihatan jarang total  gejala dini obstruksi
arteri retina sentral
 Merupakan tanda paling sering pd insufisiensi arteri
karotis/tdpt emboli pd arteri oftalmik retina
Pemeriksaan & DD
 Funduskopi
 Tidak ditemukan kelainan fundus krn pendeknya serangan
 Kadang terlihat adanya plak putih atau cerah atau suatu
embolus dalam arteriol
 DD
 Migren
 Papil edema
 Miopia
 Anemia
 Polisitemia
 Hipotensi
 Kelainan darah
Tatalaksana
 Pengobatan pd peny arteri karotis  aspirin 325 mg &
berhenti merokok, kontrol diabetes / hipertensi sbg
penyebab
 Pd peny jantung  aspirin 325 mg 4x sehari dgn
pertimbangan bedah jantung & kontrol semua risiko yg
berhub dgn arterosklerosis
 Salisilat & obat mobilisasi sel darah
Central retinal venous occlusion
Definition & epidemiology
 common and easily diagnosed retinal vascular disorder
with potentially blinding complications

 Patients are usually over 50 years of age, and more than


50% have associated cardiovascular disease
Clinical manifestation & diagnosis
 sudden painless loss of vision

 Clinical appearances
 a few small scattered retinal hemorrhages
 cotton-wool spots to a marked hemorrhagic appearance with
both deep and superficial retinal hemorrhage
 rarely may break through into the vitreous cavity
Classification
 Central Retinal Vein Occlusion
 Macular dysfunction
 persistent decreased central vision as a result of chronic macular
edema
 Th/ 
 Intravitreal triamcinolone has limited effect
 Trials of intravitreal injections of depot steroid or anti-VEGF agents
have shown promising results
 Branch Retinal Vein Occlusion
 occurs at the site of an arteriovenous crossing
 Reduction in visual acuity only occurs if the macula is affected
 Retinal neovascularization may develop if retinal capillary
nonperfusion exceeds five disk diameters in area
 Th/ 
 peripheral retinal neovascularization develops  sectoral retinal laser
photocoagulation to the area of ischemic retina
 reduces the risk of vitreous hemorrhage by one-half
 vision loss due to macular edema persists for several months without
spontaneous improvement  grid-pattern macular argon laser
photocoagulation
 Intravitreal injection of steroids or anti-VEGF agents may be useful in
macular edema unresponsive to laser treatment
Central retinal artery occlusion
Sign & symptoms
 painless catastrophic visual loss occurring over a period of
seconds
 afferent pupillary defect can appear within seconds, preceding
the fundus abnormalities by an hour
 Branch retinal artery is usually embolic in origin and results in
visual field loss

 Fundoscopy
 superficial retina becomes opacified due to ischemia
 foveal cherry-red spot is evident
 visualization of the choroidal pigment and retinal pigment epithelium
through the extremely thin retina overlying foveola
 resolves within 4–6 weeks, leaving a pale optic disk as the major ocular
finding
Treatment
 Irreversible retinal damage occurs after 90 minutes of
complete central retinal artery occlusion in the subhuman
primate model  quick therapy
 anterior chamber paracentesis and intravenous
acetazolamide
 Sudden decrease in intraocular pressure resulting in increased
retinal perfusion
 Inhaled oxygen–carbon dioxide mixture induces retinal
vasodilation and increases the PO2 at the retinal surface
 Thrombolytic therapy
 infused directly into the ophthalmic artery or administered
systemically, continues to be evaluated
Neuritis optik
Etiologi & epidemiologi
 Etiologi
 Idiopatik
 Sklerosis multipel sedang pada anak o/ morbili, cacar air,
parotitis
  Dapat merupakan gejala dini penyakit multipel sklerosis

 Epidemiologi
 Perempuan >, 20-40 thn bersifat unilateral
Klasifikasi
 Neuritis unilateral
 e/ Multipel sklerosis; th/ steroid (< peradangan &
memperpendek periode akut penyakit)
 Dapat sembuh spontan dalam 4-6 mg
 Neuritis bilateral
 e/ tidak diketahui pasti, penyakit Devic, atrofi papil herediter
Leber, keracunan alkohol/tembakau, kelainan metabolik (DM),
neuropati tropik, kurang gizi, neuritis optik bilateral pd anak
Tanda & gejala
 Rasa sakit di sekitar mata terutama bila mata digerakkan
 Pegal & sakit bila dilakukan perabaan pada mata yg sakit
 Kehilangan penglihatan beberapa jam – hari pd 1/kedua
mata pd usia khusus 18-45 thn
 Sakit pd rongga orbita terutama pd pergerakan mata
 Penglihatan warna terganggu
 Tahda Uhthoff (penglihatan < setelah olahraga atau suhu >)

 Perjalanan penyakit
 Turunnya tajam pengllihatan mendadak intermiten (maksimal 2
minggu) & sembuh kembali dgn sempurna  atrofi papil saraf optik
parsial/total
 Pada 1 mata terlihat defek pupil aferen relatif (Marcus
Gunn pupil)
 Terdapat sel dalam badan kaca
 Edem papil dengan perdarahan lidah api (anak &
pemuda)
 Papil normal pada proses retrobulbar
DD
 Iskemik otak neuropati (tidak sakit, skotoma altitudinal)
 Edema papil akut
 Hipertensi berat
 Toksik neuropati
Pengobatan
 Pengobatan sesuai kausa
 Kortikosteroid / ACTH
 + antibiotik
 Vasidiltasia & vitamin

 Will Eye Manual


 keadaan akut
 Visus >= 20/40  observasi
 Visus <= 20/50 
 Observasi
 Metilprednisolon 250 mg IV  prednison tablet
Neuritis intraokular/papilitis
 Radang pd serabut retina saraf optik yg masuk pada papil
saraf optik yg berada dlm bola mata

 Tanda & gejala


 Penglihatan terganggu (lapang pandang menciut, bintik buta
melebar, skotoma sentral; sekosentral; altitudinal)
 Teradapat tanda defek pupil pd 1 mata/tdk sama pd kedua mata
 Papil perdarahan, eksudat, perubahan pemb darah retina (arteri
menciut dgn vena melebar)
 Edema papil berat menyebar ke retina sekitar (<2-3 dioptri)
 Eksudat star figure dr papil ke makula
 Papil berangsur pucat/putih
 Terlihat sel radang di dalam kaca, depan papil saraf optik
A 22-year-old woman
noticed a sudden decrease
in vision in her right eye
and pain on eye movement

The disc is elevated and the


margins blurred, with
opacification of the nerve
fiber layer inferiorly
DD
 Iskemik optik neuropati
 Papil edema akut
 Hipertensi sistemik akut
 Leher optik neuropati
 Optik neuropati toksik & metabolik
Neuritis retrobulbar
 Radang saraf optik dibelakang bola mata
 Akut, bilateral

 Etiologi
 Sklerosis multipel, penyakit mielin saraf, anemia pernisiosa, DM,
intoksikasi

 Tanda & gejala


 Terasa berat di belakang bola mata saat digerakkan
 Rasa sakit bertambah bila bola mata ditekan & disertai sakit kepala
 Gejala = neuritis optik; dgn gambaran fundus normal (lama
kelamaan terdapat kekaburan batas papil saraf optik, degenerasi
saraf optik, & atrofi desendens)
 Keadaan lanjut  reaksi pupil lambat
 Diagnosis & pemeriksaan
 Pemeriksaan lapang pandang  skotoma sentral, parasentral,
cincin
 Turunnya tajam penglihatan
Retinopati serosa sentral
Definisi & epidemiologi
 Keadaan lepasnya retina dari lapis pigmen epitel di
daerah makula akibat masuknya cairan melalui membran
bruch & pigmen epitel yg inkompeten
 Bersifat residif, laki2 20-50 thn, perempuan hamil & usia
> 60 thn

 Patologi, tanda & gejala


 Tertimbunnya cairan di bawah makula  gangguan fungsi
makula  visus <, metamorfopsia, hipermetropia + skotoma
relatif & positif (kelainan pada uji Amsler kisi2)
 Visus 20/20-20/80
 Menyembuh kira2 8 minggu dgn tdk trdpt kebocoran lagi
(cairan subretina akan diserap & retina melekat kembali)
Pemeriksaan & pengobatan
 Pemeriksaan
 Funduskopi  terangkatnya retina (sangat kecil & dpt seluas
diameter papil)
 Lepasnya retina dr epitel pigmen akibat cairan pada subretinal dapat
dilihat dgn pemeriksaan angiografi fluoresesin
 Uji Amsler  penyimpangan garis lurus disertai skotoma
 Berkurangnya fungsi makula  kemampuan melihat warna
 Pengobatan
 Melihat letak kebocoran
 Bila terdapat penurunan visus akibat gangguan metabolisme 
fotokoagulasi
References
 Guyton AC. Textbook of medical physiology. 22nd ed.
New York: McGraw-Hill Companies, Inc, 2005
 Juncqueira LC, Cerneceiro J, Kelley RO. Basic histology 8th
ed. Connecticut: Appleton & Lange, 1995
 Moore KL. Clinically oriented anatomy. 5th edition.
Baltimore: Lippincot William & Willkins, 2005
 Paul Riordan-Eva, John PW. Vaughan & Asbury general
ophtalmology. 17th ed. USA: McGraw-Hill, 2008
 Sidarta Ilyas. Ilmu Penyakit mata. Edisi keempat. Jakarta:
FKUI, 2007